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FOR I N STRUCT I ONS, S EE S A C , . OF FORMT h i s f o r m i s n o t a p p l i c ab l e t o s t a t u t o r y p o l i t i c a l c o mmi t t e e s .No t i c e o f Di s s o l u t i o n
J AN 1
Ev e r y Not i c e o f Di s s o l u t i o n s h a l l b e a c c o mp a n i e d b y ac o mp l e t e d Di s c l os u r e Re p o r t F or m c u r r e n t t o t h e da t e o fd i s s o l u t i o n .
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FORMDR- 2( Re v . 0 1 / 2 0 0 1 )
F o r O f f i c e Us e On l yComm. #I n d e x e dA u d i t e dCo mp u t e r
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I MPORTANT : I n d i c a t e t y p e o f c o mmi t t e e y o u a r e r e p o r t i n g f o r :( 7 ) S t a t e w i d e i L e g i s l a t i v e C a n d i d a t e ( 2 ) S t a t e w i d e PAC ( 3 ) S t a t e P a r t y ( 4 ) C o u n t y / L o c a l C a n d i d a t e( 5 ) C o u n t y PAC ( o ) B a l l o t I s s u e / F r a n c h i s e C o mmi t t e e ( 7 ) C o u n t y i C i t y C e n t r a l C o mmi t t e e( 8 ) S u p p o r t S t a t e o f C a n d i d a t e sCANDI DATE COMMI TTEES ONLY:Ca nd i d a t e Name
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Ro u t i n e P e n a l t i e s Du e F a r L at e F i l e d Re po r t s Range f r om $ 20 t o $800SEE I NSTRUCTI ONS ON BACK AND COMPLETE7 HE FOLLOWI NGSENTENCE :I AM F I L I N GA~-~-~- - - ! 4 - ~ ? " 1 , o
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L o c a l C o mmi t t e e s , e n t e r D a t e o f E r e c t i o n
C h e c k i f t h i s i s f i n a l ( t e r mi n a t i o n ) r e p o r t a n d a t t a c h N o t i c e o f D i s s o l u t i o n F o r m DR- 3 .( Y o u mus t c o n t i n u e t o f i l e r e p o r t s u n t i l a N o t i c e o f D i s s o l u t i o n i s f i l e d . )
STATEMENT OF CASH ON HANDCASH ON HAND a t t h e b e g i n n i n g o f t h e r e p o r t i n g p e r i o d . ( T h i s i s t h e t o t a l o f a l l mo v i e s h e l db y t h e c o mmi t t e e . T h i s amou n t MUST b e t h e s ame a s t h e c a s h o n h a n d a t t h e e n d
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FOR I NSTRUCTI ONS . SEESAr " ' OF FOR&I
" TATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONSMADE TO STATEWI DE OR LEGI SLATI VEANDI DATES . L I ST THE CANDI DATE I DENT I F I CA TI ON NUMBER I N THE DESI GNATC- J COLUMN ANDTHE- AC CHECK NUMBER FOR EACH EXPENDI TURE. A L I ST OF 1 0 NUMBERS I S AVAI LABLE FROM THE I OWAFi r i I CS S CAMPAI GN DI SCLOSURE BOARD.COMMI TT EENAME I Mu s t b e same a s o n S t a t e m e n t o f O r g a n i z a t i o n )
/ - r ~ ( L1 f e . S S . c ~ SGLr e -i n c - i l u. dd c (CT r NSCe, . , q c ( LA . -EXPENDI TURES - MONEY SPENT FROM COMMI TTEE ACCOUNT
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~dd. l 2 . S S - 2 - t i SUse- ; - x L l Kdea(or5 c J _R _ J L - I * ' - ' A)FOR I NSTRUCTI ONS SEEBAOFFOR&1 SCHEDULEEXPENDI TURES - - MONEY SPENT FROMCOMMI TTEE ACCOUNTBMONETARY( Re v . 0 9 / 9 7 ) EEXPENDI TURI" TATE PAC COMMI TTEES : NOTE: FOR CONTRI BUT I ONS MADE TO STATEWI DE OR L EGI SL A T I V EANDI DATES, UST THE CANDI DATE I DE NT I FI CA T I ON NUMBER I N THE DES I GNATED COLUMN ANDTHE? AC CHECK NUMBER FOR EACH EXPEND I TURE . A L I ST OF I D NUMBERS I S AVAI LABLE FROMTHE I OWAci H I CS & CAMPAI GN DI SCL OSURE BOARD.COMMI TTEENAME1Mus t be same a s o n St a t e me n t o f Or g a ni z a t i o n)
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FOR I NSTRUCTI ONS, SEERACKOF =ORMD( SDLGSVi k E S k , . . J I MARY PAGE
COMMI TTEE NAM ( Mu s t b e s ame a s o n St a t e me n t o f O r g a n i z a t i o n )_ l ~ t E t _ SFo R At Ao / Tz r ReDi A - t , r TCZ
I MPORTANT : I n d i c a t e t y p e o f c o mmi t t e e y o u a r e r e p o r t i n g f o r :( 1 ) S t a t e w i d e / L e g i s l a t i v e C a n d i d a t e ( 2 ) S t a t e w i d e PAC ( 3 ) S t a t e P a r t y ( 4 ) C o u n t y / L o c a l C a n d i d a t e( 5 ) C o u n t y PAC ( 6 ) B a l l o t l s s u e i F r a n c h i s e C o mm i t t e e ( 7 ) C o u n WC 1 t y C e n t r a l C o mmi t t e e( 8 ) S u p p o r t S l a t e o f C a n d i d a t e sCANDI DATE COMMI TTEES ONLY :Cand i a t e Name
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STATEMENT OF CASH ONHANDCASH ON HAND a t t h e b eg i n n i n g o f t h e r e p o r t i n g p e r i o d . ( T h i s i s t h e t o t a l o f a l l mo n i e s h e l db y t h e c o mmi t t e e . T h i s amou n t MUST b e t h e s ame a s t h e c a s h o n h a n d a t t h e e n d
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Fo r I n s t r u c t i o n s , Se e Back o f Fo r mCONTRI BUTI ONS - - MONEYTAKE) . I N
( i n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t e me n t o f Or g a n i z a t i o n )
/ Vc EL SE - F o 9 A - t t D1 7 _ a~ COMMt TTLe -STATE CAND I DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I S T THE P AC I D ENT I F I CAT I ONNUMBER AND THE P AC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVA I LABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : Se c t i o n 6 8B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r ma t i o n c o p i ed f r o m r e p o r t s an d s t a t e me n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r an y c omme r c i a l p u r p o s e by an y p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c o mmi t t e es .
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NAME AND ADDRESS OF CONTRI BUTOR
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COMMI TTEE NAME ( Mu s t b e s ame as o n S t a t eme n t o f O r g a n i z a t i o n )I
4 1 e L - S L&)
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Co" t I ISTATE CANDI DATES NOTE: I F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I C AL ACTI ON COMMI TTEE) , UST THE PAC I DENT I F I CAT I ONNUMBERAND THE PAC CHECKNUMBER I N THEDESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVA I L ABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : Se c t i o n 68 B . 3 2 A ( 6 ) , I o wa C o d e , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s an d s t a t e me n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r an y c omme r c i a l p u r o o s e b y an y p er s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c o mmi t t e e s .
DATE
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F o r I n s t r u c t i o n s , See Back o f Fo r m SCHEDULECONTRI BUTI ONS - MONEYTAKEr v I N A MONETARY( Re v . 0 6 / 9 7 ) RECEI PTS( I n c l u o i n g c a n d i d a t e ' s p e r s o n a l f u n d s )
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Fo r I n s t r u c t i o n s , See Back o f Fo r mCONTRI BUTI ONS - - MONEY TAKE . IN
( i n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTEENAME ( Mu s t b e s ame as o n S t a t eme n t o f O r g a n i z a t i o n )
J U ) L L S ( c ' J - - Z ) 2 A- " 0 r 1 -09 C6MN+ 1 7ME i _ _STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( POL I T I CAL ACT I ON COMMI TTEE) , L I ST THEPAC I D ENT I F I CAT I ONNUMBER AND THEPAC CHECK NUMBER I N THEDESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVA I LABLE FROMTHE I OWA ETHI CS ANDCAMPAI GNDI SCLOSURE BOARD.CAUTI ON : Sec t i on 6 8B . 3 2A( 6 ) , I o wa Code, p r o h i b i t s t h e u s e o f i n f o r ma t i o n c o p i e d f r o m r e p or t s an d s t a t e me n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r an y c omme r c i a l p u r p o s e b y an y p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c ommi t t e es .
SO9
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PAC I D NUMBER
( i f a p p l i c a b l e )AND PAC CHECKNUMBER
NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI PTO CANDI DATE'( i f a p p l i c a b l e )
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( Re v . 0 6 / 9 7 )
RECE I PTSQCHECKTHI S EOX I FAMENDI NG FORM
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" : I F FORRECEI VED FUND-RAI SERI NCOME
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F o r I n s t r u c t i o n s , Se e B a c k o f Fo r mCONTRI BUTI ONS - - MONEY TAKE? . A
( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TT EE NAME ( Mu s t b e s ame a s on S t a t e me n t o f Or g a n i z a t i on )
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F o r I n s t r u c t i o n s , Se e B a c k o f Fo r mCONTRI BUTI ONS - - MONEY T AKE i v I N
( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TT EE NAME ( Mu s t b e same a s on St a t eme n t o f O r g a n i z a t i o n )
A 4 , / G Ls I n J r z s 2 Ai t 4 t y - o p -STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I CA L ACTI ON CCMMI TT E= ; , L I S T THE PAC I DENTI F I CAT I ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : Se c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c op i e d f r o m r e p o r t s a n d s t a t e me n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r an y c omme r c i a l p u r p o s e b y a n y p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c o mmi t t e e s .
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MONETARYRECE I P T SDATE PAC 1 0 NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT v I F F ORRECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECEIVED FUND-( MM/ DD/ YR) AND PAC CHECK ( i f a p p l i c a b l e ) RAI SER
NUMBER I NCOME
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F o r I n s t r u c t i o n s , Se e Ba c k o f Fo r mCONTRI BUTI ONS - MONEYTAKEw I N
( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TT EE NAME ( Mu s t b e s ame a s o n S t a t e me n t o f Or g a ni z a t i o n)
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STATE CANDI DATESNOTE: I F A CONTRI BUT I ON I S RECEI VED FROMA STATE PAC ( P OL I T I C A L ACT I ON COMMI TTEE ) , L I S T THE PAC I DENT I F I CAT I ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD.CAUTI ON : Se c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r ma t i o n c op i e d f r om r e p o r t s a n d s t a t e me nt s f o r s o i i c i t i n g c o n t r i b u t i o n s o rf o r a ny c omme r c i a l p u r p o s e by any p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c ommi t t e e s .
PAC I D NUMBER( i f a p p l i c a b l e )AND PAC CHECK
NUMBER
NAME AND ADDRESS OF CONTRI BUTOR
RELAT I O NSHI PTO CANDI DATE '( i f a p p l i c a b l e )
SCHEDULEA MONETARY( Re v . 0 6 / 9 7 ) 1
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" + I F FORFUND-RAI SERI NCOME
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F o r I n s t r u c t i o ns , See Back o f Fo r mCONTRI BUTI ONS - MONEYTAKE: . I N
( i n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTEENAME ( Mu s t be s ame a s o n St a t e me n t o f O r g a n i z a t i o n )N t L5r , 1 F&2 A- aD t r &R- CzAAA i t
STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I ST THE PAC I D ENT I F I CA T I O NNUMBER ANDTHE PAC CHECX NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVA I L ABL E FROMTHE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : Sec t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i ed f r o m r e p o r t s a n d s t a t emen t s f o r s o l i c i t i n g c c n mbu t i o n s o rf o r a n y c o mme r c i a l p u r p o s e by a ny p er s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c o mmi t t e es .
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DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT v I F FORRECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND-( MM/ DD/ YR) ANDPAC CHECK ( i f a p p l i c a b l e ) RAI SER
NUMBER I NCOME
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Fo r I n s r r u c t i o n s , Se e B a c k o f F o r mCONTRI BUTI ONS - MONEYT AKE . IN
( i n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TT EE NAME ( Mu s t be s a me a s o n St a t e me n t o f Or g a ni z at i o n)
S CHEDUL EA MONETARY( Re v . 0 6 / 9 7 ) 1 RECE I PTS
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STATE CANDI DATES NOTE: I F A CONTRI BUT I ON I S RECEI VED F R OM A STATE PAC ( P OL I T I C AL ACT I ON COMMI TTEE) , US T THE PAC I DENTI F I CATI ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN. A US T OF I D NUMBERS I S AVAI L A BLE FROM THE I OWA ETH I CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : Se c t i o n 68 B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r ma t i o n c o p i ed f r o m r e p o r t s an d s t a t e me n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r an y c o mmer c i a l p u r p o s e by an y p er s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c o mmi t t e es .
PAC I D NUMBER
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AND PAC CHECKNUMBER
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v I F FORFUND-R AI S ERI NCOME
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F o r I n s t r u c t i o n s , Se e B a c k o f FonnCONTRI BUTI ONS - MONEY TAKBsv I N
( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TT EE NAME ( Mu s t b e s ame a s o n S t a t e me n t o f O r g a n i z a t i o n )
STATE CANDI DATES NOTE: I F A CONTRI BUTI ON I S RECEI VEDFROM A STATEPAC ( POL I T I CAL ACTI ON COMMI TTEE ) , L I ST THE PAC I DENT I F I CAT I ONNUMBER ANDTHE PAC CHECKNUMBER I N THEDESI GNATED COLUMN . A L I ST OF I D NUMBERS I S AVA I L A B L E FROMTHE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD.CAUTI ON : Se c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Cod e , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s a n d s t a t e me n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a n y c omme r c i a l p u r p o s e b y a n y p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c o mmi t t e e s .
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Fo r I n s t r u c t i o ns , See Back o f Fo r mCONTRI BUT I ONS - MONEY T A KE i v I N
( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTEE NAME ( Mu s t b e same a s o n S t a t eme n t o f O r g a n i z a t i o n )
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F o r I n s t r u c t i o n s , Se e B a c k o f Fo r mCONTR I BUTI ONS - - MONEY TAKExm I N
( i n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TT EE NAME ( M u s t b e s ame a s o n St a t e me n t o f O r g a n i z a t i o n )
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CHECKT HI S B OX I FAMENDI NG FORM
STAT E CANDI DATES NOTE : I F A C ON TRI BUTI ON I S RECE I VED FROM A STATE PAC ( POL I T I CA L ACT I ON COMMI TTEE) , L I S T T HE PA C I DENT I F I CAT I ONNUMBER AND THE PA C CHECK NUMBER I N T HE DESI GNATED COL UMN . A L I ST OF I D NUMBER S I S A VA I L A BL E FROM T HE I CWA E T HI C S AN D CAMPAI GNDI SCLOSURE BOARD.C AUT I ON : S e c t i o n 6 8 A . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e us e o f i n f o r ma t i o n c o p i e d f r om r e p o r t s a nd s t a t eme nt s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a n y c omme r c i a l p ur p o s e b y a n y p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c ommi t t e e s .
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NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI PT O CANDI DATE'( i f a p p l i c a b l e )
1: I F FOPFUND-RAI SEPI NCOME
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F o r I n s t r u c t i o n s , Se e Ba c k o f Fo r mCONTRI BUTI ONS - MONEY TAKE: v I N
( i n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMM177EE NAME ( Mu s t b e s ame a s on St a t e me n t o f Or g a n i z a t i on )
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STATE CANDI DATES NOTE: I F A CONTRI BUT I ON I S RECEI VED FROM A STATE PAC ( P O L I T I C A L ACT I ON COMMI TTEE) , L I S T T H E P AC I DENT I F I CAT I ONNUMBER AND THE PAC CHECK NUMBER I N T HE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVA I LABLE FROMT HE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : Se c t i o n 6 8 H . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r ma t i o n c op i e d f r o m r e p o r t s a n d s t a t e me n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a n y c o mme r c i a l p u r p o s e by a n y p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c ommi t t e e s .
DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR R ELA T I ONSHI P AMOUNT v I F FORRECE3VED ( i f a p p l i c a b l e ) TO CANDI DATE ' RECEI VED FUND-( MMl DDf YR) AND PAC CHECK ( i f a p p l i c a b l e ) RAI SERNUMBER I N COME
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F o r i n s t r u c t i o n s , Se e B a c k o f Fo r mCONTRI BUTI ONS - MONEY T AK Ei v I N
( i n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )I COMMI TTEENAME ( Mu s t b e s ame a s o n St a t e me n t o f Or g a n i z a t i o n)
STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I S T THE P AC I D ENT I F I CA T I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVA I LABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCL OSURE BOARD .CAUTI ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Code, p r o h i b i t s t h e u s e o f i n f o r ma t i o n c op i e d f r o m r e p o r t s a n d s t a t e me nt s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a n v c o mme r c i a l p u r p o s e b y a n y p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c ommi t t e e s .
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F o r I n s t r u c t i o n s , Se e Back o f Fo r mCONTRI BUTI ONS - - MONEYTAKE . IN
( i n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TT EE NAME ( Mu s t b e s ame as o n St a t e me n t o f O r g a n i z a t i o n )N I E - S b , 1
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CAUTI ON : Se c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r ma t i o n c o p i e d f r o m r e p o r t s an d s t a t e me n t s f o r s o l i c i t i n g c on t n b u t i o ns o rf o r an y c omme r c i a l p u r p o s e b y an y p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c o mmi t t e e s .PAC I D NUMBER
NAME ANDADDRESS OF CONTRI BUTOR( i f a p p l i c a b l e )
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SCHEDUL EAI MONETARY( Re v . 0 6 / 9 7 ) RECEf PTSQCHECKT HI S BOX I F
AMENDI NG FORM
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FORI NSTRUCTI ONS, SEEBACKCORM' T AT E PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADETO STATEWI DE OR LEGI SLATI VE4 NDI DATES, L I S T THE CANDI DATE I DENTI F I CATI ON NUMBER I N THE DESI GNATED COLUMN AND THEPAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I ST OF I DNUMBERS I S AVAI LABLE FROM THE I OWAETHI CS & CAMPAI GN- DI SCL OSURE BOARD .COMMI TTEE NAME ( Mu s t b e s ame as o n St a t eme n t o f O r g a n i z a t i o n )
EXPENDI TURES - - MONEYSPENT FROM COMMI TTEE ACCOUNT
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FOR I NSTRUCTI ONS . SEEBACK CORNIZTATEPACCOMMI TTEES : NOTE : FORCONTRI BUTI ONSMADE TO STATEWI DEOR LEGI SLATI VEANDI DATES . L I ST THE CANDI DATE I DENT I F I CAT I ON NUMBER I N THE DESI GNATED COLUMN ANDTHEPAC CHECKNUMBER FOREACH EXPENDI TURE . AL I ST OF I D NUMBERS I S AVAI LABLE FROMTHE I OWA
ETHI CS & CAMPAI GN DI SCLOSURE BOARD.COMMI TTEENAME ( Mu s t De s ame a s on S t a t e me n t o f Or g a ni z a t i o n)
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FOR I NSTRUCTI ONS . SEE BACK CORI WEXPENDI TURES - MONEY SPENT FROM COMMI TT EE ACCOUNT
I TATE PAC COMMI TT EES : NOTE: FORCONTRI BUTI ONS MADETOSTATEWI DE OR LEGI SLATI V EANDI DATES, L I ST THE CANDI DATE I DENT I F I CATI ON NUMBER I N THE DESI GNATED COL UMN AND THEPAC CHECK NUMBERFOR EACH EXPENDI TURE . A L I ST OF I D NUMBERS I S AVAI LABLE FROM THE I OWAETHI CS & CAMPAI GNDI SCLOSURE BOARD .COMMI TT EE NAME ( Mu s t b e s ame a s o n St a t e me n t o f O r g a n i z a t i o n )
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FOR I NSTRUCTI ONS . SEEBACK(ORA+ 1EXPENDI TURES - MONEY SPENT FROMCOMMI TTEEACCOUNT- TATE PAC COMMI TT EES : NOTE: FOR CONTRI BUTI ONS MADE TO STATEWI DE OR L EGI SL AT I V EANDI DATES, L I ST THE CAND I D ATE I DENT I F I CAT I ON NUMBER I N THE DESI GNATED COLUMNAND THEt J A C CHECK NUMBER FOR EACH EXPEND I TURE . A L I ST OF I D NUMBERS I S AV A I L ABLE FROMTHE I OWAETHI CS & CAMPA I GN. DI SCL OSURE BOARD .
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NAME AND ADDRESS TOWHOMEXPENDI TURE{ D i s b u r s e m e n t ) WAS MADE
PURPOSE( DESCRI BE TRANSACTI ON)
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FORI NSTRUCTl oNS, SEsBAr - oFFoRl h lSCHEDULEEXPENDI TURES - MONEYSPENT FROMCOMMI TcEACCOUNTBIMONETARY" TATE PAC COMMI TT EES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR LEGI SLATI VEANDI DATES, UST THE CANDI DATE I DENT I F I CATI ON NUMBER I N THE DESI GNATED COLUMN AND THEHAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I ST OF I D NUMBERS I S AVA I LABLE FROM THE I OWA_=I HI CS & CAMPAI GN DI SCLOSURE BOARD .COMMI TT EE NAME ( Mu s t b e s ame as o n St a t eme n t o f O r g a n i z a t i o n )( Re v . 0 9 / 9 7 ) EXPENDI TURE:Q CHECK THI S 3OX I FAMENDI NG FORM>~ r &r se>JCANDI DATEDATE I D NUMBEREXPENDED ( i f a p p l i c a b l e )( MM/ DD/ YR) AND PACCHECKNUMBER
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FOR I NSTRUCTI ONS, SEE- : BAC" OFFORI h JEXPENDI TURES - MONEY SPENT FROM COMMI TTEE ACCOUNT" TATE PACCOMMI TT EES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR LEGI SLAT I VEANDI DATES . USTTHE CANDI DATE I DENT I F I CAT I ON NUMBER I N THE DES I GNATED COLUMN AND THESAC CHECK NUMBER FOR EACH EXPENDI TURE . A UST OF I D NUMBERS I S AVA I LABLE FROM THE I OWAci HI CS & CAMPAI GN DI SCLOSURE BOARD .
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PURPOSE( DESCRI BE TRANSACTI ON)
B MONETARY( Re v . 0 9 / 9 7 ) IEXPENDI TUREpCHECK THI S BOX I FAMENDI NG FORM
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F . ARY LOANS RECEI VED THI S REPORTI NG PERI OD, i a l s o ur c e o f l o a n , s u c h a s a b a n k , mu s t b e s h own i f a t h i r d p a r t y i s
- ) I v e d i n c l u d e l o a n s f r o m c a n d i d a t e ' s p e r s o n a l f u n d s . )
TOTAL ( PART I ) $ - 20p5'
* D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mmi t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v ema k i n g a c o n t r i b u t i o n t o t h e c o mmi t t e e R e l a t i o n s h i p mus t b e s h own t o t h e t h i r d d e g r e e o fc o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a nd a f f i n i t y ( r e l a t i v e s b y ma r r i a g e ) ( Se e Pa g e 2 o f f o r msp a c k e t . ) I f s u r n a me o f c o n t r i b u t o r i s t h e s a me a s c a n d i d a t e , b u t t h e r e I s n o f a m i l i a le n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l umn when i t a p p l i e s
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